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Your Job (i.e. intensivist, CCRN, etc.)

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Dave Cotterill

I assume many of us will side with the defense here given our chosen professions. I think both sides did a great job at pleading their case, and while the theatrics provided by the prosecution did a great job to convey poor care to the jury, the merits of the decisions, when weighed by medical professionals, just feel to be on the side of the defense. ECMO, retrograde intubation, some of these procedures, at least where I’m from, are almost unheard of and to insinuate that you would have to be uneducated to not consider them is ridiculous to me.

This patient recieved unparalleled care, in my opinion, and I hope a jury would agree and find this doctor totally vindicated in his decision making.

Cheers from Nova Scotia! Love the podcast and absolutely loved this particular case. Goes to show how a lawyer can skewer a skilled physician on a stand. Makes you really rethink your documentation standards.

Not guilty. As there is no evidence for critical desaturation mentioned, the airway problems were a red herring. If severe hypoxia or impending loss of airway were present, some form of advanced airway management would have been necessary – but this did not occur. It’s not clear to me even that the ED management would have contributed to her death if the case happened today. She died of MODS, not of acute shock – it is unclear if more rapid titration of epi would have prevented this (though, being based in Europe, the doses mentioned seem rather small to me). I’d have to see the chart to know if titration was done quickly enough. I would not prescribe 100 mcg IV bolus for a mentating patient if a drip was quickly available. Final issue is the quinolone. I do feel that this is an unnecessarily risky medication to use here. Infection is unlikely to be a major contributor so quickly (acid burn might be), and alternatives exist. I would label this below the standard of care – but no evidence is presented that this ended up causing harm (most mistakes don’t, fortunately). RE ECMO – would that even work in… Read more »

What's Your Job?

IM/CC resident

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1 year ago

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tom fiero

good points, Maarten. retro-vision is often better, if not 20/20. but there’s much to consider. some thoughts: 1. if one decides that the airway is to be secured , if that decision is made, there is a certain pathway that one can follow. scott has multiple pods on this site discussing just this one issue. the difficult and the failed airway. the horrific video of the Elaine Bromley case comes to mind. the seven intubation attempts in the mock trial case remind me in a way of that. in 2013 , scott described the STC-shock trauma center failed airway algorithm. yes, there may be several algorithms out there, but one wonders what rich levitate or scott would have done. LMA and cricothyrotomy (regardless of a goiter) might have been pursued, much earlier. 2. the plaintiff lawyer describes assigning a single ” naysayer” in the room. it was about at that point that he began to lose my faith in his arguments. that never seems to be problem in my code-room. 3. retrograde needle/guide wire ET intubation argument. i thought this is mostly thought to be a very bad idea. LMA, yes. Video-Assisted laryngoscopy, certainly. 4. scott and others have hammered… Read more »

The airway issue is such a red herring, not relevant to outcome from info provided, but concerning given the way it was approached.
The antibiotic issue: weird choice (geographic differences I suspect), but just random guessing from the plaintiff.
Glucagon: reasonable to try. Reasonable dose. Could have gone higher if more adrenaline had failed.
ECMO: whatevs. Wasn’t standard of care in 2008. Don’t think it would be necessary with proper management.

Adrenaline: this is the negligence. Either you suspect anaphylaxis and you treat to your end point (reasonable MAP and oxygenation) or you take a step back and reconsider your diagnosis and management plan. I think the diagnosis is clear here (were there tryptases taken in the actual case?) from the information given. A sufficient dose was not given. It seems surprising given the doctor’s supposed experience with anaphylaxis that he didn’t crank the dose higher. There is no upper limit. If he didn’t think it was working, then he should have called a CV ICU for advice.

The patient died from MOF from undertreated distributive (anaphylactic) shock. Guilty.

What's Your Job?

ICU and Physician Registrar

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1 year ago

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Matthew D

A jury of EM physicians being polled will likely lead to a different verdict than that of the typical jury. I think both sides argued well however the plaintiff’s argument was more effective. I think this is true in most cases as it is far easier to argue something different should have been done when there is a poor outcome than it is to defend the actions which clearly could have changed in hindsight as per the art of medicine and variations in acceptable practice. The plaintiff argued for a long time regarding the intubation however this was not a case of hypoxic respiratory arrest and the delay in obtaining a secure airway was not the cause of this patient’s death. Perhaps enough doubt would be sewed into the jury by this line of questioning however to erroneous lead to a conclusion that the physician was indeed negligence. Did the physician have a duty? Yes Was there a violation in the standard of care? No Was there an injury caused by negligence? No Significant damages? Yes (death) but not caused by negligence I would side with the defendant, but I would not be surprised if judgement ended up being against… Read more »

Patient presented to primary care with some relatively non specific symptoms prior to attending ed. So some of the symptoms preceded the new drugs she was given.

Failure to respond to adrenaline (sorry epinephrine) and the goitre make me wonder about other possible differentials (just grabbing at straws for fun). I am no endocrinologist so my apologies for any lack of understanding!

– lrti with assoc aki -> Propranolol toxicity

– That goitre is interesting no? Impending myxoedema coma perhaps precipitated by infection could explain altered mental state, bradycardia, hypotension and oedema (including difficulty cannulating). Against this the Propranolol makes it more likely she is hyperthyroid…

Be good to know the labs obviously..

Don’t think I can criticise the management from a jobbing internal medicine/gastro perspective but wonder about the securoty of the diagnosis. It feels like something clever and endocrine to this hard of thinking gastroenterologist.

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IM/gastro

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1 year ago

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Mark

It’s an interesting point but to my mind the temporality of the symptoms and signs go against this. Given drugs by her GP – sudden acute onset shortness of breath, rash, then acutely increasing airway oedema does not fit with tempo of myxoedema. Altered mental status was said to be in keeping with anxiety on triage note, similarly fitting with anaphylaxis more so than myxedema coma. And indeed, tempo and case details seem classic for anaphylaxis.

What's Your Job?

ICU Registrar

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1 year ago

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Patrick Switzer

Not guilty!
Defense witness did a good job deflecting the prosecution’s assertions that the airway issue killed the patient. I think defense could have done better job emphasizing the riskiness of all the airway options that the prosecution was touting as easy-cheezy-“no brainer”s. I’m guessing I’ve never heard of retrograde intubation for a reason- in the youtube video I just watched it took the team 5 minutes to get it done, sans goiter, which is probably why ED providers aren’t keen?

I actually agree with the prosecutor that the defendant saying “we decided” repeatedly made it sound like he was passing the buck, even though he was probably just trying to emphasize using/consulting his expert colleagues.

Curious- how many of you would go with glucagon in a patient with borderline airway? The patients I’ve given it to usually vomit regardless of antiemetics…

Great episode and really entertaining/thought provoking. The prosecutor did an awesome job being an infuriating, wrong-and-strong bastard.

What's Your Job?

RN

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1 year ago

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tom fiero

good thought on the glucagon, patrick. emesis is certainly not a desired effect here. (could you imagine? in this airway?) and
2. i kind of (maybe wrongly) like the beta-2 blockade of the lopressor on board, allowing less- opposed alpha, i.e., vasoconstriction (one of the major concerns here in this presumed distributive shock.

yes. the plaintiff’s lawyer played a nice bad guy. not sure if that is a good thing , if you want to win a case.

think i prob would have tried the glucagon but certainly no where near the levels the plaintiff attorney alluded to

What's Your Job?

emcritter

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1 year ago

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Maarten Van Hemelen

Not guilty. As there is no evidence for critical desaturation mentioned, the airway problems were a red herring. If severe hypoxia or impending loss of airway were present, some form of advanced airway management would have been necessary – but this did not occur. It’s not clear to me even that the ED management would have contributed to her death if the case happened today. She died of MODS, not of acute shock – it is unclear if more rapid titration of epi would have prevented this (though, being based in Europe, the doses mentioned seem rather small to me). I’d have to see the chart to know if titration was done quickly enough. I would not prescribe 100 mcg IV bolus for a mentating patient if a drip was quickly available. Final issue is the quinolone. I do feel that this is an unnecessarily risky medication to use here. Infection is unlikely to be a major contributor so quickly (acid burn might be), and alternatives exist. I would label this below the standard of care – but no evidence is presented that this ended up causing harm (most mistakes don’t, fortunately). RE ECMO (today), I’m out sure of this… Read more »

What's Your Job?

IM/CC resident

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1 year ago

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lettuce

not guilty, more because plaintiff side used wrong arguments, speculated and misinterpreted words (i know it’s their work, but sometimes it frightens me when i see this in action). Agree with other comment, that it is difficult to judge your proffesion, colleagues.
Is there a room for learning here – yes. I learned a lot from this “trial” and it was interesting to watch.
There are a lot of things to comment on, but still, on i thing i don’t agree with defence is : ABC stays ABC, regardless of hemodynamics oxygenation should be done appropriately – decause even if MAP is low, some perfusion happens, especially in vital organs.

Excellent Podcast ! I have to go with “Not Guilty” either, i don’t think there’s any action that could have prevented the final outcome in this patient. 1) Quinolone I don’t think the administration of another antibiotic would have change the outcome. 2) Airway management I don’t think a more aggressive airway management would have change the outcome in this patient. However, i was a bit uncomfortable with “We focused on circulation since the patient was oxygenating well and protecting her airway”. Just to be clear, i am not saying i would have done a better job, it’s pretty easy to criticize the case in front on my laptop 😉 In my opinion, when you take the option “RSI the patient” there is no intermediate exit, the only possible final endpoint is a tube at the right place. In this case i see only two possible option : 1) Look like a difficult airway, sat is OK, no big swelling progressing, you have time -> Awake intubation, if it fails, plan to call ENT for a nice double set-up intubation in the OR 2) Look like a difficult airway, Airway is potentially dynamic, Sat is Ok but patient is going… Read more »

well obv. you and i are going to be on the same page given how we have interacted, but for people who feel necessary to call anesthesia in a case like this (showing level of airway familiarity/exp) then waiting for drug to wear off is not a bad idea. this pt would have been perfect for awake intubation, reason not chosen is familiarity.

What's Your Job?

emcritter

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1 year ago

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tom fiero

not guilty.
a beautiful (though very painful to watch) presentation. these are always, i think, difficult, for inherent reasons. however, they are invaluable, or certainly could be. that is why i had found the monthly Risk-Management series (by dr greg henry and his team) of podcasts valuable, informative, enlightening. mike weinstock was an occasional guest if i recall. years back, they recommended a book by Mike called “bouncebacks”. i finally purchased it three days ago.

thank you, scott for giving us this, and thank you of course, to mike weinstock, and his team.

painful, invaluable.

tom

ps: this video is the tip of the iceberg, of course. the discussions of representation, the effect of being named, on the doc, and his psyche, the effect on his family, regardless of the details and final decisions made, is the much larger iceberg.

What's Your Job?

ed doc, merced,ca.

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1 year ago

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tom fiero

am i allowed one more thought?

although i have no love for the plaintiff’s lawyer, he comments on ECMO. while that was not commonly used (i believe) in 2008, the time of this case, today it is a significant powerful tool/option in appropriate cases, including anaphylaxis.

please enjoy the incredible pod (by the Reanimate team of scott, joe bellezzo, and zack shinar) on the edecmo.org site: pod #31. exactly this scenario, i think.

not sure if this pt was really ecmo eligible, should have gotten much higher and additional pressors and prob. would have been fine

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emcr

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1 year ago

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Andreas

I don´t understand the role of ECMO in this case. The problem is primarily vasoplegic shock and an AV ECMO doesn´t help with that, the pat would likely have a hyper dynamic circulation with increased cardiac output. The cases Ive found seems to be patients already in cardiac arrest secondary to anaphylaxis. The role for VV ECMO does also not seems to be fulfilled as the pat was not refractory hypoxic.

Can someone explain to me what I don’t understand?

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Anesthesia

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1 year ago

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Dale

What was the actual verdict? Wondering if a jury of layperson would follow the case and come to the same conclusion as most of the docs here.

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Cardiac Anesthesia Fellow

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1 year ago

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Catherine Perry

My verdict would be for the defense. But I would bet money that a lay jury would find for the plaintiff